Ecobiosocial Community Intervention for Improved ... - Springer Link

EcoHealth 11, 434–438, 2014 DOI: 10.1007/s10393-014-0953-8

Ó 2014 International Association for Ecology and Health

Short Communication

Ecobiosocial Community Intervention for Improved Aedes aegypti Control Using Water Container Covers to Prevent Dengue: Lessons Learned from Girardot Colombia Tatiana Garcı´a-Betancourt,1 Catalina Gonza´lez-Uribe,1 Juliana Quintero,1 and Gabriel Carrasquilla1 Centro de Estudios e Investigacio´n en Salud CEIS Fundacio´n Santa Fe de Bogota´, Carrera 7B No 123 – 90 Piso 3, Bogota´, Colombia

INTRODUCTION Dengue is the most important mosquito-borne viral disease worldwide (WHO 2012). Its incidence has grown dramatically around the world in recent decades making it a major public health concern (Badurdeen et al. 2013; Brathwaite Dick et al. 2012; Morens et al. 2013). Over 40% of the world’s population is now at risk from dengue and the disease is endemic in more than 100 countries. The Americas, South-east Asia and the Western Pacific regions are the most seriously affected. Colombia in South America, was classified as the eighth most highly endemic country between 2004 and 2010 (WHO 2012). In 2010, the country suffered the worst registered epidemic with 157,203 cases, 147,426 dengue cases and 9,777 severe dengue, with a lethality of 2.26% (230 deaths). The year 2013 was an important epidemiological year with epidemic outbreaks registered in Colombia and neighbouring Latin American countries (OPS 2013). The predominant dengue vector is Aedes aegypti, a domestic mosquito species whose breeding sites are related to environmental factors linked and maintained by human behaviours—individual, collective and institutional—and their related social, economic and political contexts (Powell and Tabachnick 2013). Until a vaccine becomes available Published online: June 25, 2014 Correspondence to: Tatiana Garcı´a-Betancourt, e-mail: tatiana.garcia@ecosaludetv colombia.org

for public health use, primary prevention remains dependent upon institutional, social and dengue vector control programmes, which include domestic environmental management such as source reduction, provision of safe water, covering and screening of water containers, and reduction of vector to human contact through the use of insecticide-treated nets in windows and doors (Erlanger et al. 2008). This study sits within the project entitled Ecobiosocial approach for the design and implementation of a sustainable strategy for dengue vector control in Girardot (Girardot libre de dengue in Spanish), which is based on a multi-country effort developed following a TDR/IDRC proposal on Innovative Community-Based Ecosystem Management Interventions for Improved Chagas and Dengue Disease Prevention in Latin America and the Caribbean. Girardot is located 120 km from Bogota, the capital of the country and presents ecological (289 MASL) and climatic conditions [Mean temperature 28 °C, rainfall 821 mm and humidity 80% with a dry (December–April) and rainy season (May–October)] that make the city one of the most endemic municipalities of dengue in the country. Long-lasting insecticide-treated curtains on windows and water containers were selected as suitable interventions based on the literature (Kroeger et al. 2006; Lenhart et al. 2008; Seng et al. 2008; Vanlerberghe et al. 2010; TDR 2006) and the results of phase one of the project (Quintero et al. 2014). First, natural populations of A. aegypti in Girardot

Ecobiosocial Community Intervention for Dengue in Girardot, Colombia

were susceptible to pyrethroids molecules authorised by public health authorities (Santacoloma Varo´n et al. 2010). Second, in our specific study area traditional prevention and control programmes are vertically organized with incomplete implementation of their activities. Third, phase one of the project provided evidence that low-water recipients for water storage (cement large or plastic water containers of >200 L) with no protective measures against mosquito oviposition are the main productive sources for larvae and pupae. Of all pupae collected, more than 80% were found in these breeding sites. Other considerations taken into account for selecting the intervention were that no studies had been conducted in Colombia using longlasting insecticide net materials for dengue vector control, representing an innovative strategy in our specific study area. In addition, the observed opportunity to involve the community in the design, elaboration and implementation of the intervention as an income generation activity was a key factor from an Ecohealth approach. During the first phase (July 2010 and August 2011), the research team carried out a transdisciplinary study under the Ecobiosocial framework to assess linkages between ecological, biological and social factors and the current A. aegypti density in urban areas of Girardot and to determine a baseline. The second phase (January 2012–March 2014) corresponds to the construction, implementation and evaluation of long-lasting insecticide-treated curtains on windows and doors, and covers in productive large water containers using a cluster-randomised trial design to assess effectiveness in reducing vector indexes, specifically pupa per person index. This paper focuses on the challenges of implementing the water container covers. Our first challenge was to involve the community from an Ecobiosocial approach in the development of the intervention. Social participation is a cornerstone of Ecohealth Research, therefore, it is necessary to design participation tools and empowerment mechanisms as part of the research process when working with local communities (Charron 2010). The local context was diverse and meant facing different challenges such as street violence and insecurity in socioeconomically deprived clusters, absent household members due to working schedule of the population and seasonal migration patterns. Social participation was achieved through ethnographic work that included establishing trust, socialising the objectives of the project and constructing communication channels with neighbourhood community leaders previously identified during fieldwork as key local actors. We developed 10

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workshops with the community, one for each intervention cluster called ‘Creating water container covers’. The objective of this activity was to create a bond between the activities of the project and the needs and expectations reported by the participants about the intervention. To ensure social participation, the research team visited each cluster to present the project and invite participants. Each visit was accompanied by local neighbourhood leaders and the participants were asked to set the meeting days and times and the research team adapted to the communities’ schedule. During the workshops, the participants formulated a design concept for the water container cover identifying materials, advantages and disadvantages and possible elements that could restrict the construction of the intervention measure. Each workshop lasted about 1 h and a half and a total of 10 workshops were conducted in Girardot (February–May 2013), with 111 participants in total (Figure 1). The workshops followed three guideline topics: curtain use, water container cover and advantages and disadvantages of the cover design. One participant from each group was chosen to present the final idea design and explain the materials, advantages and disadvantages of their design. Most of the groups (four groups) chose aluminium considering it a more durable but expensive material followed by wood (three groups) that was judged inexpensive. Other groups preferred polyvinyl chloride plastic (PVC) or bamboo as materials because of lightweight and manageability. Major concerns regarding the covers referred to children’s manipulation and adjustment to irregular water container shape covers that could not be adapted for proper use and location of water faucet (Figure 2). The results were systematised and socialised with the extended research team. Two community ideas were selected and prototype models were instaled in four houses to discuss in situ by members of the house, the project research team and a local aluminium frame maker. One design was chosen based on the community’s evaluation of price, materials, durability and practicality; the selected model was an aluminium frame with a sliding window for use. A second challenge involved the manufacture and installation process of the water container cover for each house. The aim was to translate the concerted knowledge in the workshops into a sustainable participatory process that would allow us to construct and instal the water container covers. This phase of the project included technical and logistic difficulties. A key technical issue was the wide diversity of shapes and sizes of the water containers (Figure 3) hence, no single standard generalizable model

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Figure 1. A Community Workshop with seven participants (two men and five women) to design water container covers in the Rosablanca neighbourhood of Girardot, Colombia, on 2 May 2013. B Sketch of Rosablanca neighbourhood container cover design. C Community Workshop with ten participants (four men and six women) to design water container covers in the Sucre neighbourhood of Girardot, Colombia, on 2 May 2013. D Sketch of Sucre neighbourhood container cover design.

could be massively produced to save time and money. Instead, the research team measured up individually all lowwater tanks (n = 1,001) during survey visits, but all houses had to be re-visited by the local producer of the covers to verify measurements based on the final concerted design in the workshops. This verification process was executed in two weeks to prevent further delays. A rigorous process of measuring the water containers is fundamental to optimise materials and time once a final design is selected. Time spent re-visiting houses could instead be used in other activities of the intervention. Another technical issue was the need to modify the design for households with irregular shaped water containers. For example, fabric covers in circular shaped water containers were made based on the measurement of the circumference of the container (n = 60) and 3% of covers were not built due to the irregular shapes that needed an alternative design and materials, for example L shape and semi lunar forms. This aspect remains a challenge and has been outlined as a crucial aspect to overcome in future scaling-up phases. To encourage sustainability, a local company was selected to involve local residents and develop employment

opportunities through the project. The research team selected three small local companies to elaborate and instal the water container covers in a period of one month according to the project timeline. Working with local actors, in this case the three companies that elaborated the covers, is beneficial for the project because they are familiar with the context and reside in the city and they can monitor the installation and replicate the intervention in future phases. The principal challenge of the implementation phase was the unplanned extra time and resources spent during cover production and household installation. This process was prolonged due to delays in the product delivery caused by the inexperience and small size of the local companies to handle this type of projects that require field work, different product sizes and time spent measuring the dimensions of water containers. The lessons presented here add valuable information to the preparation, implementation and future scaling up of similar intervention programmes with an Ecohealth approach. The principal result of this strategy at this stage was the acceptance of the water container covers by the residents. Community involvement in the creation and elab-

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Figure 2. Diversity of shapes, materials and sizes of large water containers.

Figure 3. The process of making water container covers: (1) Ariulfo Loaiza employee of a local company cutting the aluminium frame (2) Installation of the cover and (3) water container with cover installed.

oration process was crucial for the acceptance of the project and to achieve an intervention measure that can be sustainable and replicable in the future. Listening to the ideas of the community and integrating key actors into transdisciplinary teams was a vital mechanism of social participation for the decision-making process and implementation of the intervention. Community-based interventions require more time and resources than classical interventions due to longer socialisation and negotiation processes that are needed to achieve social participation

and the expectations of the community involved, but result in stronger ties between local actors and the project critical to the sustainability of local projects with an Ecohealth approach.

ACKNOWLEDGMENTS The authors thank local leaders, stakeholders and field workers, especially Sandra Marta Lozano, field supervisor,

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without them this project would not be possible; Colette Gouffray and Oscar Carrillo for their kindness and hospitality; the research team of Ecosalud ETV Colombia in Bogota´ who support technical and field activities; Health authorities of Girardot, particularly Dr Magda Caicedo for supporting the fieldwork and other activities of the project; TDR/WHO for financial support; and the residents of Girardot for welcoming our team into their homes and actively participating in this project.

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